Investigation and inquest
On 29/06/2016 I commenced an investigation into the death of Jane Louise Reason aged 57. The investigation concluded at the end of an inquest on 13th October 2016. The conclusion of the inquest was Natural causes.
Circumstances of the death
The deceased was a lecturer at King Edward VI College in Stourbridge. She was found collapsed at her place of work at 12.50 on 28/04/16. Staff commenced CPR until a first responder arrived at 12.59 followed by an ambulance crew at 13.12 who then continued CPR. On arrival of the ambulance crew a technician applied defibrillator pads but did not deliver a shock despite one being indicated. When further ambulance staff attended they were able to deliver a first shock however when they attempted to deliver a second shock the defibrillator battery failed. Another battery was obtained from the ambulance. There was a delay of 13 minutes in delivering the shock. The deceased was taken to Queen Elizabeth Hospital in Birmingham where she arrived at 13.55. She was declared deceased at 14.03. The evidence provided confirms the delay in providing a shock did not contribute to her death.
Following a post mortem/Based on information from the Deceased’s treating clinicians the medical cause of death was determined to be:
1a. HYPERTENSIVE HEART DISEASE
Coroner’s concerns
1. Evidence at the inquest confirmed that the greatest chance of survival following an arrhythmic out of cardiac arrest is with early defibrillation and CPR. I heard evidence that there was a need for more public access defibrillators particularly in colleges and school. Further consideration needs to be given to the placement of public access defibrillators and education of the public in their use.